In order to get the best care possible, I agree to the Practice obtaining my records from my previous Doctor. 

I also understand that I will be removed from their practice register.

My declaration of entitlement and eligibility*

I am eligible to enrol because:

My agreement to the enrolment process*

I intend to use this practice as my regular and on-going provider of general practice / GP / health care services.

I understand that by enrolling with this Practice I will be included in the enrolled population of Pegasus Health Charitable Ltd PHO 

(Primary Health Organisation) and my name address and other identification details will be included on the Practice, PHO and National 

Enrolment Service Registers.

I understand that if I visit another health care provider where I am not enrolled I may be charged a higher fee.

I have been given information about the benefits and implications of enrolment and the services this practice and PHO provides along 

with the PHO’s name and contact details. 

I have read and I agree with the Use of Health Information Statement. The information I have provided on the Enrolment Form will be 

used to determine eligibility to receive publicly-funded services. Information may be compared with other government agencies but 

only when permitted under the Privacy Act.

I understand that the Practice participates in a national survey about people’s health care experience and how their overall care is 

managed. Taking part is voluntary and all responses will be anonymous. I can decline the survey or opt out of the survey by informing 

the Practice. The survey provides important information that is used to improve health services.

I agree to inform the practice of any changes in my contact details and entitlement and/or eligibility to be enrolled